Synopsis On 12 March 1992, the Canadian ferry QUEEN OF ALBERNI, under the conduct of the master, departed from Tsawwassen, British Columbia, bound for Nanaimo, British Columbia, and the Japanese bulk carrier SHINWA MARU, under the conduct of a British Columbia coast pilot, departed from Roberts Bank Terminal (Westshore Terminals) en route to the Victoria Pilot Station. The vessels collided approximately one nautical mile south-west of Tsawwassen Ferry Terminal in daylight, with calm weather conditions and visibility reduced by fog. The Board determined that the QUEEN OF ALBERNI and the SHINWA MARU collided in dense fog because all available means were not used by both vessels to assess risk of, and avert, collision in a rapidly developing close-quarters situation. 1.0 Factual Information 1.1 Particulars of the Vessels 1.1.1 Description of the Vessels The QUEEN OF ALBERNI is a double-ended ferry. A navigation bridge... ...and a wheel-house are located some 42 m from each end. The forward end is considered to be that end from which the vessel is being navigated. The vessel's main propulsion consists of two diesel engines with a total output of 11,860 BHP driving a single, right-handed, controllable-pitch (CP) propeller at each end. The main engines and shafts are unidirectional, and ahead and astern are obtained by blade pitch adjustments. The vessel has a rudder at each end. For normal navigation between ports, the vessel is operated in mode 1, in which all power is transmitted to the aft propeller and bridge control is by a T handle control, giving the vessel the following speeds: For manoeuvring, the vessel is placed in mode 2, in which control of the forward propeller is achieved by an L handle control, and separate control of the aft propeller is accomplished using the T handle control. When the L handle control is used in mode 2, an ahead setting on the propeller pitch gives the vessel a braking effect and an astern setting assists in propelling the vessel forward. The fully automated SHINWA MARU is fitted with a bulbous bow. The crew accommodation, bridge and engine-room are located aft of the nine cargo hatches. The navigation bridge is positioned 247 m from the bow and 43 m from the stern. The conning position provides an unrestricted view forward. Engine control is by electric telegraph which transmits orders to a second console, also in the wheel-house, where an engineer operates the main engine. The vessel's designed service speed is about 14 knots (kn). 1.2 Description of the Occurrence After loading passengers and vehicles, the QUEEN OF ALBERNI departed Tsawwassen No. 5 dock at 08013 on 12 March 19924, in fog and near-zero visibility. Two radars were operational and the vessel was on hand-steering. Appropriate fog signals were sounded and a look-out was posted forward on the upper deck. The vessel left the No. 5 dock on a course approximately parallel to the dock's main axis 223 true (T). After the last dolphin in the west wall was cleared, the course was altered to 240 gyro (G) rather than the normal 275 (T) to allow two vessels, observed on the radar to be in the nearby northbound traffic lane, to pass ahead. No gyro error was reported. At 0805, the engine-room was notified that the vessel was on full away, but that the engines would remain on stand-by due to reduced visibility. At 0806, the engine control was switched to mode 1. Reportedly, for the brief period before collision, the vessel had reached a speed of about 8 kn which is equivalent to a CP setting of 4 on the telegraph. The speed on the doppler log located in the wheel-house was not observed. Following radio communication with the SHINWA MARU and without positively identifying her on the radar plan position indicator (PPI), the vessel continued on passage. Before the collision, the CP was set to 0 then reversed to full astern, but this action was too late. The vessels collided at 0808. The bow of the QUEEN OF ALBERNI contacted the port side of the SHINWA MARU some 25 m aft of the forward perpendicular and some 3 m above the waterline. The angle of impact was about 70. On 12 March 1992, the SHINWA MARU was port side to alongside Westshore Terminal No. 1, Roberts Bank, B.C., on a heading of 108 (T), where she completed loading 147,743 tonnes of coal shortly before 0700. A B.C. coast pilot, five tugboats and one mooring boat were in attendance. The vessel commenced singling up at 0715 and cleared the wharf at 0740. With the vessel heading 150 (T), four of the tugs were dismissed and the vessel was under her own propulsion. Because visibility was reduced, three crew members were positioned forward as look-outs and the automatic fog signal was activated. With the one remaining tugboat secured to her starboard bow, the SHINWA MARU was increasing engine revolutions per minute (RPM) and altering course to starboard with the intention of entering the southbound traffic lane. At 0800, with the vessel heading approximately 170 (T) at a speed of about 3 kn, the last tugboat was dismissed. Shortly afterward, at 0801, the QUEEN OF ALBERNI was heard reporting her departure from Tsawwassen ferry terminal to the Vessel Traffic Services (VTS). At 0806, the vessel established very high frequency radiotelephone (VHF R/T) contact with the QUEEN OF ALBERNI to arrange safe passage, but at 0808, the vessels collided. The speed of the SHINWA MARU was about 4.5 kn. 1.2.1 Events Following Collision Immediately after the collision, both vessels assessed their damage. They maintained radio contact and, after ensuring that neither vessel was in need of immediate assistance, each proceeded to port; the QUEEN OF ALBERNI to Tsawwassen Terminal and the SHINWA MARU to a safe anchorage in English Bay. Following the collision, the public address (PA) system on the ferry was used to keep the passengers informed, and first aid was rendered to the injured persons. Meanwhile, emergency vehicles were summoned. As soon as the ferry docked, emergency personnel attended to the injured passengers and crew. No person from the ferry was designated to guide the emergency response teams and to direct their efforts which resulted in some delay in evacuating the injured passengers. 1.3 Injuries to Persons None of the 11 crew members of the SHINWA MARU were injured. 1.4 Damage The ferry sustained structural damage to the shell plating, main deck apron, upper deck and sliding doors; all at No. 1 end. Some metal cabinets and food counters in the vessel's cafeteria, which were secured to the deck, had sheared off at the base and were displaced. The overhanging main deck plating of the QUEEN OF ALBERNI penetrated the port side shell plating in way of the No. 1 cargo hold and No. 1 topside ballast tank on the SHINWA MARU. Plating was set in heavily and torn open in the respective compartments. Several frames, associated members and air pipes in way were also damaged. 1.5 Vessel Certification Both vessels were certificated, equipped and manned in accordance with existing regulations. 1.5.1 Personnel Certification and History The master and officers of both vessels were in possession of certificates that were valid for their positions and for the trade in which they were engaged. The pilot on the SHINWA MARU held a Canadian Master 350 Tons Certificate of Competency issued in 1977 and a B.C. Coast Pilot's Licence. He had attended the Vessel Handling Course in Port Revel, France, in 1986. The pilot had some six years' pilotage experience on the B.C. coast. Before he became a pilot, his sea experience consisted of service on B.C. coast tugs in various capacities. The master joined the British Columbia Ferry Corporation (BCFC) in 1965. He had sailed in various capacities, working his way up the ranks and, since 1982, had served in the capacity of chief officer/relief master on large vessels. He had been sailing on this vessel and on the Nanaimo-Tsawwassen route since 1991. The officer of the watch (OOW) had approximately 20 years of sea service on BCFC vessels. Since 1986, he had been acting as watchkeeping officer on various ferries and routes. The master had approximately 27 years of sea service on various cargo vessels, of which about 11 years were in the capacity of master, including eight months on this vessel. 20 years of sea service on various cargo vessels as either deck or radio officer, and seven months on the SHINWA MARU in a dual capacity as a deck and radio officer. 1.6 Weather and Tidal Information 1.6.1 Forecasts The marine forecast issued by the Pacific Weather Centre of Environment Canada at 0445 PST on 12 March 1992, for the Strait of Georgia was: Winds light. Visibility near zero in extensive fog. Outlook, light to moderate southeasterlies. 1.6.2 Weather as Reported by the Vessels Both vessels reported a light north-westerly wind, rippled sea and visibility reduced by fog. The SHINWA MARU reported that the visibility was about 90 m ( cable), and the QUEEN OF ALBERNI defined the visibility as zero. 1.6.3 Tide and Current The collision occurred some 1 hour 17 minutes before high water at Tsawwassen. The tidal range was 0.2 m. There was no evidence to suggest that the current was a factor in this occurrence. 1.7 Navigation Equipment The vessel was equipped with two Sperry radars in each wheel-house. A conventional radar was located on the port side and a Rasterscan (RASCAR), equipped with a Collision Avoidance System (also referred to as Automatic Radar Plotting Aid (ARPA)), with a 340 mm diameter display on the starboard side. Both radars were functional and operating, but only the RASCAR was in use. The RASCAR, according to the manufacturers, is a solid-state, computer-controlled, radar system which encompasses advanced digital techniques to reduce clutter and eliminate false target signals. A wheel-house logbook entry made some 30 minutes before the collision shows that there was no deficiency with respect to machinery, navigation and safety equipment. However, following the collision, the master reported that the persistence of a clutter resulted in the echo of the SHINWA MARU not being detected. Following the collision, the radar was checked for performance and found to be functioning satisfactorily. The navigation equipment aboard the vessel included two radar sets. All navigation equipment was reported to be in good working order. The SHINWA MARU tracked the QUEEN OF ALBERNI on its radar prior to the collision. 1.8 Radio Communication 1.8.1 Vessel Traffic Services (VTS) and/or Coastal Radio Station At 0703, the SHINWA MARU informed Vancouver VTS of her intention to depart in 15 minutes, at which time VTS indicated that no other traffic had been cleared to depart. At 0756, VTS was informed that the SHINWA MARU was off the berth and under way, heading toward the traffic lane. VTS advised the vessel of the traffic in the vicinity, but there was no mention of the QUEEN OF ALBERNI. At 0801, the QUEEN OF ALBERNI reported to VTS that she was just departing Tsawwassen Terminal. VTS informed her of the traffic in the vicinity including the presence of the SHINWA MARU, just away from Roberts Bank Terminal, southbound; the SURUGA MARU, awaiting the former's berth; and three northbound vessels approaching the ferry route. The message was acknowledged and no detailed position information was sought. 1.8.2 Inter-Ship5 The first radio contact between the two vessels was initiated by the SHINWA MARU at 0806 and, about two minutes later, the vessels collided. Highlights of the communication between the vessels included the following: 08:06:22SM ... You can see me out here ...? 08:06:27QA ... We know you are there, ... wish us to slow down or may we cross your bow? 08:06:32SM I'm only doing about 5 knots but I'm coming up to full so you go ahead, it's your pleasure there. 08:06:39QA OK, we'll slow down ... 08:06:46SM Well, you can go ahead of me if you want but I'm picking up speed here. It will be quite a while before I'm up to speed but, like I say, I'm working her up. 08:07:15QA We'll keep our eye on you and stay clear of you. 08:07:40SM You seem to be coming right at me ... 08:07:58QA We're stopping SHINWA MARU. 08:08:37 SM ... You just smacked into us. 1.8.3 Maritime Vocabulary The Standard Marine Navigational Vocabulary was not used by either vessel to communicate. The International Maritime Organization (IMO) Resolution A.474(XII), adopted on 19 November 1981, entitled Proper Use of VHF Channels at Sea, encourages the use of the Standard Marine Navigational Vocabulary. The use of the latter publication in communications is intended to eliminate misunderstanding, which is crucial for operational safety. The manoeuvring terminology contained in the vocabulary ensures that each vessel is fully aware of the intentions of the other and it eliminates indecisiveness. It emphasises the need to repeat any part of the message which is considered to be sufficiently important to need safeguarding e.g. Do not, repeat, not cross ahead. Further, it reiterates that where a message contains instructions or advice, the receiving station acknowledging the message should repeat the substance (See AppendixA). 1.9 Vessel Traffic Services (VTS) Both the SHINWA MARU and the QUEEN OF ALBERNI participated in the VTS system. All vessels in the vicinity of Tsawwassen-Roberts Bank terminals were monitored on the Vessel Traffic Centre (VTC) radar. Their positions as determined by the VTC radar tracker were logged by the Central Processing Unit (CPU) and known to the Marine Traffic Regulator (MTR). The VTC tracker records all tagged targets' positions at a predetermined time interval. The accepted VTC practice is to park the tags in a non-traffic area when a vessel is alongside a berth. Only when a MTR links the tag to its target, does the tracker commence logging the updated coordinates. The assigned tag N92Q to the QUEEN OF ALBERNI was linked to the target at 08:03:09 and the K32K, to the SHINWA MARU at 08:05:45. The targets were logged by the automatic computer logger at an interval of about two and a half minutes. All VTC automatically recorded times and positions are within one second accuracy in time/Latitude/Longitude. The VTC tracker logged merging of the two targets in position 4859'44N, 12309'34W, i.e. 1.1 nautical miles (M) 237.5 (T) from Tsawwassen dock No .5 entrance light, at 08:08:28. 1.10 Reconstructed Tracks of the Vessels Both vessels had just departed the harbour limits. There was minimal information regarding plotted positions on Canadian Hydrographic Service (CHS) chart No. 3463 or in the deck logbooks. The TSB reconstructed the tracks of the SURUGA MARU, the SHINWA MARU and the QUEEN OF ALBERNI based on the information provided by the vessels and/or VTC (see AppendixB). An examination of the tracks indicated the following: At 0806, the SHINWA MARU and the QUEEN OF ALBERNI were approximately 0.73 M apart and the SHINWA MARU was some 20 on the starboard bow of the QUEEN OF ALBERNI bearing about 260. The SURUGA MARU was some 1.25 M, bearing about 287 from the QUEEN OF ALBERNI, and was headed in an easterly direction at about 3 kn. The courses and speeds made good by the QUEEN OF ALBERNI were 225 (T) and 6.42 kn between 0801 and 0806, and 245 (T) and 15.65 kn between 0806 and the time of collision, respectively. The courses and speeds made good by the SHINWA MARU from 0801 to 0806 were 186 (T) and 4.07 kn, and 171 (T) and 4.45 kn from 0806 until the time of collision, respectively. There was virtually no change in the bearing between the two vessels. 1.11 Bridge Manning and Conduct of Navigation Some four minutes prior to sailing, the master had acquired four or five targets on the ARPA, one of which was later identified to have been the SURUGA MARU. He had also observed the presence of two distinct areas of persistent clutter. He attributed the clutter variously to a disturbance caused by the wake of tugs assisting a large vessel, a herring boil with birds feeding on it, and later to a multiple/spurious echo. He was unsuccessful in his attempt to eliminate the clutter. At the time of departure of the QUEEN OF ALBERNI, the bridge was manned by the master who had the conduct with the quartermaster at the helm. As the vessel moved away from the dock, the OOW arrived in the wheel-house and was instructed by the master to locate the SHINWA MARU on the radar. He used the same ARPA set as the master and, apart from attempts at interpreting the picture and acquiring an area of clutter, no other adjustments were carried out. Approximately two minutes later, the OOW left the radar to handle all radio communications, with the master now monitoring the radar. A very large target just beyond the clutter with no appreciable vector or heading, later identified to be the SURUGA MARU, was observed on the ARPA and was assumed, albeit mistakenly, to be the SHINWA MARU. Before departure, the master and the pilot discussed the unberthing procedures and the passage from Roberts Bank to the Victoria Pilot Station. The master monitored the vessel's progress using one of the two radars, and the OOW primarily ensured that the pilot's orders were carried out. The passing arrangement between the SHINWA MARU and the QUEEN OF ALBERNI was not effectively monitored or questioned. 1.11.1 Collision Regulations The safety and conduct of vessels in restricted visibility, as set out in the International Regulations for Preventing Collisions at Sea (COLREGS), should be governed so that, among other things: a proper look-out by all available means is maintained to make a full appraisal of the risk of collision; in determining risk of collision, all available means are used and, when in doubt, risk of collision is deemed to exist; where fitted and operational, proper use is made of the radar equipment, including radar plotting or equivalent systematic observation of detected objects and assumptions are not made on scanty information; appropriate fog signals are sounded and vessels proceed at a safe speed having due regard to the prevailing circumstances and visibility. A vessel which detects by radar alone the presence of another vessel is to determine if a close-quarters situation is developing and/or risk of collision exists. If so, avoiding action in ample time is to be taken and vessels navigated with extreme caution until the danger of collision is over; and in determining safe speed, consideration is given, among others, to the visibility, the density of traffic and the limitations of a radar set. Further, good watchkeeping practices as outlined in the IMO Resolution A.285(VIII), entitled Recommendation on Basic Principles and Operational Guidance Relating to Navigational Watchkeeping, recommends that: the presence of the pilot on board does not relieve the master or the OOW from their duties and obligations for the safety of the ship, and the OOW makes most effective use of all navigational equipment at his/her disposal. In this instance, a total of eight vessels were navigating in the area in fog and near-zero visibility. Look-outs were posted forward on the QUEEN OF ALBERNI and the SHINWA MARU. The average speed, during the two and a half minutes prior to the collision, as calculated, was 15.65 kn for the QUEEN OF ALBERNI and of 4.45 kn for the SHINWA MARU. VHF R/T contact was established between the vessels to arrange a safe passage, but the communication conveyed indecisiveness, and there was limited time to effectively monitor the evolving situation. Overemphasis was placed on the VHF arrangement and more effective use was not made of other available means to avert collision. The QUEEN OF ALBERNI was aware of the presence of two large vessels in the area of Westshore Terminal, both forward of her beam. Only one radar echo on the PPI was recognized as being that of a vessel, and the apparent absence of a second echo in the vicinity was not questioned. Instead, it was assumed that the SURUGA MARU was the SHINWA MARU, and the QUEEN OF ALBERNI continued on her passage. Only when the SHINWA MARU informed the QUEEN OF ALBERNI that the ferry was headed straight for her, did the QUEEN OF ALBERNI take last minute action. This action, which comprised setting the CP to zero and then engaging reverse propulsion, was taken too late to avert collision. No action was initiated by the SHINWA MARU. Each vessel sounded the prescribed fog signals. The fog signal heard by the forward crew on the SHINWA MARU was not reported to the bridge. There was conflicting evidence regarding the fog signals as received on board the QUEEN OF ALBERNI. The look-out maintained that he heard a fog signal coming from the vessel's starboard side which he reported to the bridge. Communication between the look-out and the wheel-house was by means of a portable radio and a telephone installation. The bridge personnel maintained having neither received the look-out's message nor heard any fog signal. The look-out reported that, following the collision, the OOW had indicated that all messages from the vessel's bow were received loud and clear. At least three passengers on the ferry, who were seated on the upper deck lounge and overlooking the bow, reported that they saw the look-out on the vessel's bow talking on his radio, pointing to starboard and running aft approximately one minute before the collision. One passenger reported having heard a fog signal other than that of the QUEEN OF ALBERNI. 1.12 Ferry Schedule At the time of the occurrence, the sailing schedule for the QUEEN OF ALBERNI was as follows: The distance between ports is about 38 M and the service speed of the vessel is 20 kn. Thus, the steaming time for the passage of 1 hour and 54 minutes does not take into consideration the weather and current. Hence, the ferry is left with some 36 minutes to carry out berthing and unberthing procedures and to discharge and load vehicles and passengers. During the hearings of the 1992 Nemetz Inquiry following a fatal accident involving a BCFC vessel, there was considerable testimony about the impact of the current schedules on safety. The report of the Commission included a recommendation, Recommendation 13, that a joint task force review scheduling and its impact upon safety. The report of the task force, in May 1993, stated, in part, that the group had found that ferry turnaround time ... gave essentially no room for flexibility ... placing personnel ... in the position of having to catch-up and having essentially no slack in which to do it. The task force data indicated that ... some catching up is possible, but by no means all ... with the very limited ability of the ships to make up lost time. The group was of the opinion that keeping on time is the single most visible indicator of performance within the BCFC ... and felt that ... safety is especially vulnerable when decisions are taken under pressure to maintain a schedule. The report continued that, barring changes, ... substantial pressure to maintain the schedule will always remain part of the everyday experience, and the report cited employees as perceiving ... strong signals from above that it is the schedule that mattered above all else. The task force report was made to the Board of the British Columbia Ferry Corporation.